9.1 The key actions in the Act part of the framework are Reviewing performance and Learning lessons (refer to HSE publication HSG65 for general guidance).
Reviewing performance
9.2 Organisations should actively use data collected during ‘Check’ to review their performance regarding the levels of fatigue experienced by their staff and to inform their understanding of whether or how fatigue contributes to near misses, incidents, and accidents in their organisation.
9.3 A review should be undertaken when:
- There has been a significant change in circumstances, such as job design, workload, or organisational changes.
- There are plans to change the existing working patterns and existing limits.
- There is a change in relevant recognised good practice standards, and limits for managing fatigue in the railways and other guided transport systems.
- Fatigue has been identified as a contributory factor in an incident investigation which gives reason to doubt the effectiveness of the arrangements.
- Monitoring has shown that standards and limits are being exceeded on a regular basis.
- KPIs or other metrics indicate adverse trends which suggest the need for change to existing controls.
- Long-term sickness, a significant number of unfilled job vacancies or industrial action results in frequent exceedances.
- There is a significant incidence of safety critical workers being stopped from carrying out safety critical work due to being unfit because of fatigue.
- There is any other reason to doubt the effectiveness of the arrangements.
9.4 So far as is reasonably practicable, the findings of the fatigue review process should be fed back into the Fatigue Risk Management System (FRMS) to ensure that fatigue controls continuously improve. However, duty holders and controllers of safety critical work should consult with staff, including safety critical workers, and their trade union / safety representatives on the arrangements needed to manage fatigue and when standards and limits are to be changed. Following consultation, duty holders should take account of the views and experiences of the safety critical workers and other staff affected, as expressed either directly or through their trade union / safety representatives.
9.5 Review arrangements should preferably, and especially in high-risk situations, include a system for periodic independent review of how effectively the FRMS is managing fatigue related risk. An occasional independent audit of the program by an external observer familiar with FRMS principles and good practices developed by other organisations can greatly improve the effectiveness and efficiency of the FRMS process.
Learning lessons
Feedback review results into the FRMS
9.6 An effective FRMS ensures that the results of the review processes are fed back into FRMS improvements. This involves acting on findings of fatigue accident investigations and near miss reports (See Investigating accidents and incidents, para 8.20) and organisational vulnerabilities identified throughout the process. Organisational learning is a key aspect of health and safety management (and why a just culture is so important – see Appendix B) because if underlying causes are not identified and communicated throughout the organisation this makes a recurrence more likely.
9.7 Improvements in the FRMS should be accompanied by feedback and publicity to affected staff, to encourage cooperative participation in managing fatigue company-wide. Company newsletters can for instance be used to help publicise the benefits and encourage staff involvement and support.
9.8 Organisations may find the suggestions in the FRMS checklist at Appendix F useful in considering the adequacy of their fatigue management arrangements, though it is important to recognise that not all the suggested items will be appropriate for all organisations – fatigue controls should be proportionate to the size and complexity of the organisation and the likely risks from fatigue.
9.9 Useful sources of guidance on Fatigue Risk Management Systems are listed in Further Information.